I read with great interest the article by Tanumihardjo et al., “New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals” published online in this journal[1]. The study attempts to determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. During the study, mean HbA1c of fully intervened patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. The authors concluded that the health program was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

The study team should be congratulated for their effort and results and I do not have any critical remarks about the study. Nevertheless, I would like to ask two questions and suggest a data sub-analysis related to the treatment of the study group.

In our observational study, focused on metabolic control of type 1 and type 2 diabetes patients treated with insulin in the Czech Republic and the Slovak Republic, we found a high level of clinical inertia resulting in a very small and clinically insignificant difference in mean HbA1c within three years[2]. Thus, we believe that any new intervention targeting long-term stabilised balance between the physician’s therapeutic approach and the corresponding patient response is important and might make positive results[3].

What were in the study authors’ opinions the most effective interventions influencing HbA1c in their program? Were medication dosage adjustments part of the intervention?

As the insulin-treated type 2 diabetes patients usually reach the worst level of metabolic control[4,5], it would be interesting to see the HbA1c analysis for insulin- and non-insulin-treated patients separately if such data are available.

We respectfully suggest taking this suggestion into account, especially if a study continuation is planned.

Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic